Art & science |
The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
DEVELOPING ADVANCED NURSING SKILLS FOR FRAIL OLDER PEOPLE An ageing population with complex needs means there is scope for a post that will sit between medicine and nursing, and offer an attractive career pathway for the specialty. Sarah Goldberg and colleagues discuss its development Correspondence [email protected] Sarah Goldberg is senior clinical academic nurse, University of Nottingham/Nottingham University Hospitals NHS Trust Jo Cooper is head of nursing and midwifery research/senior research fellow, Nottingham University Hospitals NHS Trust Catherine Russell is deputy sister on a healthcare of the older person ward, Nottingham University Hospitals NHS Trust, Nottingham Date of submission January 30 2014 Date of acceptance March 12 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com
Pictured opposite: trainee advanced nurse practitioner Laura Ferrigan with a patient
Abstract Improving hospital care for frail older people requires expertise, leadership and resources as these patients have multiple complex needs. One innovative solution to providing the skilled care necessary is to train experienced nurses to become advanced nurse practitioners (ANPs). Such roles encompass activity previously undertaken by medical staff, together with leadership, teaching, research and service development. Skills specific to caring for older people, such as comprehensive geriatric assessment, are also required. This article discusses the need for ANPs in this clinical area, a pilot that is under way in one acute trust to develop these roles, and the potential benefits and challenges that may accompany this development. Keywords Acute care, advanced nurse practitioners, comprehensive geriatric assessment, frailty FRAIL OLDER patients have complex needs, therefore improving their care in hospital requires expertise, leadership and resources (Care Quality Commission 2011). Many such patients have functional and mental health problems, such as cognitive impairment, depression and anxiety, that may result in apathy, agitation and delusions (Goldberg et al 2012). Hospital admission can be a transition point; some older people will be reaching the end of their natural life, while others are no longer able to care
20 May 2014 | Volume 26 | Number 4
for themselves at home and challenging decisions about further care environments have to be made (Bradshaw et al 2013a). It can be a difficult time for family carers. They can experience high levels of stress at the time of admission of their loved ones to hospital (Bradshaw et al 2013b); sometimes they come to the ward feeling angry about the care they have received previously (Jurgens et al 2012). However, the current crisis in nursing recruitment often means that hospital trusts are unable to fill posts (Royal College of Nursing (RCN) 2013), which compounds the problem of improving quality of care for frail older people. Investment in nursing careers is essential to ensure recruitment and retention of high calibre staff.
Complex care Hospital care of these patients requires a multidisciplinary team. A crisis in the medical workforce, identified by the Royal College of Physicians (RCP) (2012), has arisen because of the need to meet the increasingly complex clinical, care and support needs of an ageing population. Hospitals are struggling to cope with an increase in clinical demand and difficulties in recruiting staff to medical posts and training schemes that involve general medicine. The RCP raised concerns about the difficulties of delivering high quality 24-hour services and a systematic failure to deliver co-ordinated, NURSING OLDER PEOPLE
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Tim George
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Art & science | acute care Service evaluation has shown a high level of support for the advanced nurse practitioner role from consultants and ward sisters patient-centred care. They conclude that a new cadre of doctors is required to meet the needs of these patients. However, such a conclusion is narrow in its vision and more innovative solutions are required to ensure that patients are provided with the skilled care that they need. One solution to such pressing care requirements is to train experienced nurses to become advanced nurse practitioners (ANPs) who specialise in the care of frail older patients. ANPs are already established in specialties such as neonatal care, emergency departments, mental health services and in the community. In the US, the geriatric nurse practitioner role is seen as integral to ensuring high quality clinical care for patients in Nurses Improving Care for Healthsystem Elders hospitals. ANPs are trained to master’s degree level and receive formal training in activities previously undertaken by medical staff, including physical examination, ordering and interpreting diagnostic tests, advanced health needs assessments, differential diagnosis, prescribing medication and patient discharge (RCN 2012). However, this training alone is not enough for a nurse to become an ANP for frail older people. To develop sufficient competence and expertise, trainee ANPs need to work alongside geriatricians to develop specialist skills such as comprehensive geriatric assessment (CGA). There is compelling evidence that CGA improves patient outcomes (Ellis et al 2011). CGA covers five domains: medical, mental health, functional capacity, social circumstance, and environment, together with development of a management plan and case management (Martin 2010). Other skills that are critical to the role include advanced skills in dementia and delirium, palliative care, continence, polypharmacy, rehabilitation and falls. The scope of knowledge and skills required of ANPs for frail older people is potentially vast and it will take many years for them to be fully trained. Alongside their expert clinical role, ANPs will be involved in leadership, teaching, research and service development (National Leadership and Innovation Agency for Healthcare (NLIAH) 2010).
Training Nottingham University Hospitals NHS Trust is piloting the innovative new role of ANP for frail older people. The pilot has been funded for two years by 22 May 2014 | Volume 26 | Number 4
private donation and Nottingham Hospitals Charity. The funding covers employment costs of four trainee ANPs at band 7 and a 0.5 whole time equivalent project manager. The pilot includes a service evaluation to be completed at six-month intervals during the two-year period. The first stage evaluation has been completed and involved semi-structured interviews with consultant geriatricians, ward sisters and trainee ANPs; a process evaluation of how the trainee ANPs spend their working days; and a comparison of length of stay on wards where trainee ANPs are based compared with wards without trainee ANPs. Later service evaluations will include interviews with patients and family carers. Benefits of new role The service evaluation has shown a high level of support for the ANP role from consultants and ward sisters with some early benefits emerging, but it is clear that expectations of the trainee ANPs are high. Those interviewed considered that the ANPs will be in a unique position as expert co-ordinators and leaders of care, taking into account patients’ medical and nursing needs, providing comprehensive and consistent information to patients and their families. Similar benefits were identified in Williamson et al’s (2012) study of acute care ANPs. The trainee ANPs’ previous nursing experience gives them an understanding of the ‘bigger picture’ of care, and the longer-term goals of patients and their families, which junior doctors can find difficult to co-ordinate and manage. This has enabled the trainee ANPs to discuss sensitive issues with patients and their families effectively, such as end of life and discharge decisions. By having a thorough understanding of medical and nursing roles, the trainee ANPs are able to ensure that both professions work together for the benefit of patients, and minimise risks associated with poor communication and associated delays in effective care planning. Furthermore, the trainee ANPs provide ‘on the job’ training that is given in real time, resulting in better skilled ward-based staff. The clinical career pathway offered by the ANP role was also considered to be of benefit with recruiting and retaining nurses to healthcare of the older person (HCOP) teams and has been used to raise the profile of this area of nursing. Roles and boundaries Establishing the role and boundaries of the trainee ANPs is challenging. Sitting between medicine and nursing, there is a need to avoid the trainee ANPs from becoming ‘silo workers’ operating in isolation from other team NURSING OLDER PEOPLE
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members, duplicating work or creating a list of problems that no one has time to solve. In addition, they have to ensure they get sufficient learning opportunities on a busy HCOP ward where junior doctors have their own learning needs. The sheer number and turnover of staff in the multidisciplinary team creates a logistical problem to ensure everyone is educated about their role. With each junior doctor rotation, more education is needed. The trainee ANPs can potentially refer to a wide range of doctors, however many will not initially have full awareness of their role. They need excellent communication and assertiveness skills to manage the occasions when doctors from other disciplines treat them dismissively. The authors have secured leadership and communication skills coaching to support the trainee ANPs in developing these essential skills. It is anticipated that the trainee ANPs will become highly skilled staff, and as such they are likely to be desirable resources. Role boundaries are important so they are not overwhelmed and experience burnout. Role vagueness and ambiguity have been problems for others developing acute care ANP roles (Dean 2012, Dalton 2013). A study is soon to begin to gain consensus from a multidisciplinary group of experts in care of frail older people on the role and competencies required of ANPs working in HCOP. Cost of training The trainee ANP role has associated costs and ongoing funding. To achieve the anticipated benefits, substantial investment is required for their clinical and academic training. Funding for the master’s degree is provided by Health Education East Midlands, however one full
day of study leave and an additional half day of self-directed study are required each week, as well as extra study leave closer to the exams. The trainees have shown considerable commitment to the course, often studying more than ten hours a week in their own time. Considerable consultant and registrar time is also required to train them in the workplace. Further training is likely to be needed after completion of the master’s degree. It is vital that the development of these roles is not seen as short term and the organisation’s commitment to succession planning, including adequate funding for the development process, is essential to develop successful advanced practice roles (Currie and Grundy 2011).
Conclusion ANPs for frail older people are likely to be important new roles for HCOP nursing teams. We are at an early stage of developing this role, and anticipate that it will provide great benefits for patient care and a unique opportunity for nursing career development. There is still much work to be done to establish core criteria for recruitment to these roles and best evidence about how they reflect the pillars of advanced practice (NLIAH 2010), however advantages are already being seen and we are optimistic that we can develop a role that significantly improves patient care on the wards.
Online archive For related information visit our online archive and search using the keywords.
Conflict of interest None declared Acknowledgements We would like to acknowledge that the opportunity to pilot an advanced nurse practitioner role has been granted due to the kind and generous sponsorship of our own Nottingham Hospitals Charity, whose mission is to be at the heart of our patients’ care. We would also like to acknowledge the generous sponsorship of the Atkinson Morley and Amandus Club Neuroscience Research Scholarship via the Florence Nightingale Foundation, whose funding of Catherine Russell’s visit to the US was the starting point and inspiration behind this project
References Bradshaw L, Goldberg S, Lewis S et al (2013a) Six-month outcomes following an emergency hospital admission for older adults with co-morbid mental health problems indicate complexity of care needs. Age and Ageing. 42, 5, 582-588. Bradshaw L, Goldberg S, Schneider J et al (2013b) Carers for older people with co-morbid cognitive impairment in general hospital: characteristics and psychological wellbeing. International Journal of Geriatric Psychiatry. 28, 7, 681-690. Care Quality Commission (2011) Dignity and Nutrition Inspection Programme. National Overview. CQC, Newcastle upon Tyne.
NURSING OLDER PEOPLE
Currie K, Grundy M (2011) Building foundations for the future: the NHS Scotland advanced practice succession planning development pathway. Journal of Nursing Management. 19, 7, 933-942.
Goldberg S, Whittamore K, Harwood R et al (2012) The prevalence of mental health problems among older adults admitted as an emergency to a general hospital. Age and Ageing. 41, 1, 80-86.
Dalton M (2013) Perceptions of the advanced nurse practitioner role in a hospital setting. British Journal of Nursing. 22, 1, 48-53.
Jurgens F, Clissett P, Gladman J et al (2012) Why are family carers of people with dementia dissatisfied with general hospital care?: a qualitative study. BMC Geriatrics. 12, 57, 1-19.
Dean E (2012) The hybrid pioneers. Nursing Standard. 26, 50, 20-21. Ellis G, Whitehead M, Robinson D et al (2011) Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. British Medical Journal. 343:d6553.
Martin F (2010) Comprehensive Assessment of the Frail Older Patient. tinyurl.com/qezrllt (Last accessed: March 24 2014.) National Leadership and Innovation Agency for Healthcare (2010) Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales. tinyurl. com/32kb2db (Last accessed: March 26 2014.)
Royal College of Nursing (2012) Advanced Nurse Practitioners. An RCN Guide to Advanced Nursing Practice, Advanced Nurse Practitioners and Programme Accreditation. RCN, London. Royal College of Nursing (2013) Frontline First. Running the Red Light November 2013 Special Report. RCN, London. Royal College of Physicians (2012) Hospitals on the Edge? The Time for Action. RCP, London. Williamson S, Twelvetree T, Thompson J et al (2012) An ethnographic study exploring the role of ward-based advanced nurse practitioners in an acute medical setting. Journal of Advanced Nursing. 68, 7, 1579-1588.
May 2014 | Volume 26 | Number 4 23
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The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
DEVELOPING ADVANCED NURSING SKILLS FOR FRAIL OLDER PEOPLE An ageing population with complex needs means there is scope for a post that will sit between medicine and nursing, and offer an attractive career pathway for the specialty. Sarah Goldberg and colleagues discuss its development Correspondence [email protected] Sarah Goldberg is senior clinical academic nurse, University of Nottingham/Nottingham University Hospitals NHS Trust Jo Cooper is head of nursing and midwifery research/senior research fellow, Nottingham University Hospitals NHS Trust Catherine Russell is deputy sister on a healthcare of the older person ward, Nottingham University Hospitals NHS Trust, Nottingham Date of submission January 30 2014 Date of acceptance March 12 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com
Pictured opposite: trainee advanced nurse practitioner Laura Ferrigan with a patient
Abstract Improving hospital care for frail older people requires expertise, leadership and resources as these patients have multiple complex needs. One innovative solution to providing the skilled care necessary is to train experienced nurses to become advanced nurse practitioners (ANPs). Such roles encompass activity previously undertaken by medical staff, together with leadership, teaching, research and service development. Skills specific to caring for older people, such as comprehensive geriatric assessment, are also required. This article discusses the need for ANPs in this clinical area, a pilot that is under way in one acute trust to develop these roles, and the potential benefits and challenges that may accompany this development. Keywords Acute care, advanced nurse practitioners, comprehensive geriatric assessment, frailty FRAIL OLDER patients have complex needs, therefore improving their care in hospital requires expertise, leadership and resources (Care Quality Commission 2011). Many such patients have functional and mental health problems, such as cognitive impairment, depression and anxiety, that may result in apathy, agitation and delusions (Goldberg et al 2012). Hospital admission can be a transition point; some older people will be reaching the end of their natural life, while others are no longer able to care
20 May 2014 | Volume 26 | Number 4
for themselves at home and challenging decisions about further care environments have to be made (Bradshaw et al 2013a). It can be a difficult time for family carers. They can experience high levels of stress at the time of admission of their loved ones to hospital (Bradshaw et al 2013b); sometimes they come to the ward feeling angry about the care they have received previously (Jurgens et al 2012). However, the current crisis in nursing recruitment often means that hospital trusts are unable to fill posts (Royal College of Nursing (RCN) 2013), which compounds the problem of improving quality of care for frail older people. Investment in nursing careers is essential to ensure recruitment and retention of high calibre staff.
Complex care Hospital care of these patients requires a multidisciplinary team. A crisis in the medical workforce, identified by the Royal College of Physicians (RCP) (2012), has arisen because of the need to meet the increasingly complex clinical, care and support needs of an ageing population. Hospitals are struggling to cope with an increase in clinical demand and difficulties in recruiting staff to medical posts and training schemes that involve general medicine. The RCP raised concerns about the difficulties of delivering high quality 24-hour services and a systematic failure to deliver co-ordinated, NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 30, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Tim George
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 30, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | acute care Service evaluation has shown a high level of support for the advanced nurse practitioner role from consultants and ward sisters patient-centred care. They conclude that a new cadre of doctors is required to meet the needs of these patients. However, such a conclusion is narrow in its vision and more innovative solutions are required to ensure that patients are provided with the skilled care that they need. One solution to such pressing care requirements is to train experienced nurses to become advanced nurse practitioners (ANPs) who specialise in the care of frail older patients. ANPs are already established in specialties such as neonatal care, emergency departments, mental health services and in the community. In the US, the geriatric nurse practitioner role is seen as integral to ensuring high quality clinical care for patients in Nurses Improving Care for Healthsystem Elders hospitals. ANPs are trained to master’s degree level and receive formal training in activities previously undertaken by medical staff, including physical examination, ordering and interpreting diagnostic tests, advanced health needs assessments, differential diagnosis, prescribing medication and patient discharge (RCN 2012). However, this training alone is not enough for a nurse to become an ANP for frail older people. To develop sufficient competence and expertise, trainee ANPs need to work alongside geriatricians to develop specialist skills such as comprehensive geriatric assessment (CGA). There is compelling evidence that CGA improves patient outcomes (Ellis et al 2011). CGA covers five domains: medical, mental health, functional capacity, social circumstance, and environment, together with development of a management plan and case management (Martin 2010). Other skills that are critical to the role include advanced skills in dementia and delirium, palliative care, continence, polypharmacy, rehabilitation and falls. The scope of knowledge and skills required of ANPs for frail older people is potentially vast and it will take many years for them to be fully trained. Alongside their expert clinical role, ANPs will be involved in leadership, teaching, research and service development (National Leadership and Innovation Agency for Healthcare (NLIAH) 2010).
Training Nottingham University Hospitals NHS Trust is piloting the innovative new role of ANP for frail older people. The pilot has been funded for two years by 22 May 2014 | Volume 26 | Number 4
private donation and Nottingham Hospitals Charity. The funding covers employment costs of four trainee ANPs at band 7 and a 0.5 whole time equivalent project manager. The pilot includes a service evaluation to be completed at six-month intervals during the two-year period. The first stage evaluation has been completed and involved semi-structured interviews with consultant geriatricians, ward sisters and trainee ANPs; a process evaluation of how the trainee ANPs spend their working days; and a comparison of length of stay on wards where trainee ANPs are based compared with wards without trainee ANPs. Later service evaluations will include interviews with patients and family carers. Benefits of new role The service evaluation has shown a high level of support for the ANP role from consultants and ward sisters with some early benefits emerging, but it is clear that expectations of the trainee ANPs are high. Those interviewed considered that the ANPs will be in a unique position as expert co-ordinators and leaders of care, taking into account patients’ medical and nursing needs, providing comprehensive and consistent information to patients and their families. Similar benefits were identified in Williamson et al’s (2012) study of acute care ANPs. The trainee ANPs’ previous nursing experience gives them an understanding of the ‘bigger picture’ of care, and the longer-term goals of patients and their families, which junior doctors can find difficult to co-ordinate and manage. This has enabled the trainee ANPs to discuss sensitive issues with patients and their families effectively, such as end of life and discharge decisions. By having a thorough understanding of medical and nursing roles, the trainee ANPs are able to ensure that both professions work together for the benefit of patients, and minimise risks associated with poor communication and associated delays in effective care planning. Furthermore, the trainee ANPs provide ‘on the job’ training that is given in real time, resulting in better skilled ward-based staff. The clinical career pathway offered by the ANP role was also considered to be of benefit with recruiting and retaining nurses to healthcare of the older person (HCOP) teams and has been used to raise the profile of this area of nursing. Roles and boundaries Establishing the role and boundaries of the trainee ANPs is challenging. Sitting between medicine and nursing, there is a need to avoid the trainee ANPs from becoming ‘silo workers’ operating in isolation from other team NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 30, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
members, duplicating work or creating a list of problems that no one has time to solve. In addition, they have to ensure they get sufficient learning opportunities on a busy HCOP ward where junior doctors have their own learning needs. The sheer number and turnover of staff in the multidisciplinary team creates a logistical problem to ensure everyone is educated about their role. With each junior doctor rotation, more education is needed. The trainee ANPs can potentially refer to a wide range of doctors, however many will not initially have full awareness of their role. They need excellent communication and assertiveness skills to manage the occasions when doctors from other disciplines treat them dismissively. The authors have secured leadership and communication skills coaching to support the trainee ANPs in developing these essential skills. It is anticipated that the trainee ANPs will become highly skilled staff, and as such they are likely to be desirable resources. Role boundaries are important so they are not overwhelmed and experience burnout. Role vagueness and ambiguity have been problems for others developing acute care ANP roles (Dean 2012, Dalton 2013). A study is soon to begin to gain consensus from a multidisciplinary group of experts in care of frail older people on the role and competencies required of ANPs working in HCOP. Cost of training The trainee ANP role has associated costs and ongoing funding. To achieve the anticipated benefits, substantial investment is required for their clinical and academic training. Funding for the master’s degree is provided by Health Education East Midlands, however one full
day of study leave and an additional half day of self-directed study are required each week, as well as extra study leave closer to the exams. The trainees have shown considerable commitment to the course, often studying more than ten hours a week in their own time. Considerable consultant and registrar time is also required to train them in the workplace. Further training is likely to be needed after completion of the master’s degree. It is vital that the development of these roles is not seen as short term and the organisation’s commitment to succession planning, including adequate funding for the development process, is essential to develop successful advanced practice roles (Currie and Grundy 2011).
Conclusion ANPs for frail older people are likely to be important new roles for HCOP nursing teams. We are at an early stage of developing this role, and anticipate that it will provide great benefits for patient care and a unique opportunity for nursing career development. There is still much work to be done to establish core criteria for recruitment to these roles and best evidence about how they reflect the pillars of advanced practice (NLIAH 2010), however advantages are already being seen and we are optimistic that we can develop a role that significantly improves patient care on the wards.
Online archive For related information visit our online archive and search using the keywords.
Conflict of interest None declared Acknowledgements We would like to acknowledge that the opportunity to pilot an advanced nurse practitioner role has been granted due to the kind and generous sponsorship of our own Nottingham Hospitals Charity, whose mission is to be at the heart of our patients’ care. We would also like to acknowledge the generous sponsorship of the Atkinson Morley and Amandus Club Neuroscience Research Scholarship via the Florence Nightingale Foundation, whose funding of Catherine Russell’s visit to the US was the starting point and inspiration behind this project
References Bradshaw L, Goldberg S, Lewis S et al (2013a) Six-month outcomes following an emergency hospital admission for older adults with co-morbid mental health problems indicate complexity of care needs. Age and Ageing. 42, 5, 582-588. Bradshaw L, Goldberg S, Schneider J et al (2013b) Carers for older people with co-morbid cognitive impairment in general hospital: characteristics and psychological wellbeing. International Journal of Geriatric Psychiatry. 28, 7, 681-690. Care Quality Commission (2011) Dignity and Nutrition Inspection Programme. National Overview. CQC, Newcastle upon Tyne.
NURSING OLDER PEOPLE
Currie K, Grundy M (2011) Building foundations for the future: the NHS Scotland advanced practice succession planning development pathway. Journal of Nursing Management. 19, 7, 933-942.
Goldberg S, Whittamore K, Harwood R et al (2012) The prevalence of mental health problems among older adults admitted as an emergency to a general hospital. Age and Ageing. 41, 1, 80-86.
Dalton M (2013) Perceptions of the advanced nurse practitioner role in a hospital setting. British Journal of Nursing. 22, 1, 48-53.
Jurgens F, Clissett P, Gladman J et al (2012) Why are family carers of people with dementia dissatisfied with general hospital care?: a qualitative study. BMC Geriatrics. 12, 57, 1-19.
Dean E (2012) The hybrid pioneers. Nursing Standard. 26, 50, 20-21. Ellis G, Whitehead M, Robinson D et al (2011) Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. British Medical Journal. 343:d6553.
Martin F (2010) Comprehensive Assessment of the Frail Older Patient. tinyurl.com/qezrllt (Last accessed: March 24 2014.) National Leadership and Innovation Agency for Healthcare (2010) Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales. tinyurl. com/32kb2db (Last accessed: March 26 2014.)
Royal College of Nursing (2012) Advanced Nurse Practitioners. An RCN Guide to Advanced Nursing Practice, Advanced Nurse Practitioners and Programme Accreditation. RCN, London. Royal College of Nursing (2013) Frontline First. Running the Red Light November 2013 Special Report. RCN, London. Royal College of Physicians (2012) Hospitals on the Edge? The Time for Action. RCP, London. Williamson S, Twelvetree T, Thompson J et al (2012) An ethnographic study exploring the role of ward-based advanced nurse practitioners in an acute medical setting. Journal of Advanced Nursing. 68, 7, 1579-1588.
May 2014 | Volume 26 | Number 4 23
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